Improvement Of Fracture Healing Research Articles

Fracture healing on non-union fracture model promoted by non-thermal atmospheric-pressure plasma.

Non-thermal atmospheric-pressure plasma (NTAPP) is attracting widespread interest for use in medical applications. The tissue repair capacity of NTAPP has been reported in various fields; however, little is known about its effect on fracture healing. Non-union or delayed union after a fracture is a clinical challenge. In this study, we aimed to investigate how NTAPP irradiation promotes fracture healing in a non-union fracture model and its underlying mechanism, in vitro and in vivo. For the in vivo study, we created normal and non-union fracture models in LEW/SsNSlc rats to investigate the effects of NTAPP. To create a fracture, a transverse osteotomy was performed in the middle of the femoral shaft. To induce the non-union fracture model, the periosteum surrounding the fracture site was cauterized after a normal fracture model was created. The normal fracture model showed no significant difference in bone healing between the control and NTAPP-treated groups. The non-union fracture model demonstrated that the NTAPP-treated group showed consistent improvement in fracture healing. Histological and biomechanical assessments confirmed the fracture healing. The in vitro study using pre-osteoblastic MC3T3-E1 cells demonstrated that NTAPP irradiation under specific conditions did not reduce cell proliferation but did enhance osteoblastic differentiation. Overall, these results suggest that NTAPP is a novel approach to the treatment of bone fractures.

Aucubin Promotes Osteogenic Differentiation and Facilitates Bone Formation through the lncRNA-H19 Driven Wnt/β-Catenin Signaling Regulatory Axis.

Traditional Chinese medicine Cortex Eucommiae has been used to treat bone fracture for hundreds of years, which exerts a significant improvement in fracture healing. Aucubin, a derivative isolated from Cortex Eucommiae, has been demonstrated to possess anti-inflammatory, immunoregulatory, and antioxidative potential. In the present study, our aim was to explore its function in bone regeneration and elucidate the underlying mechanism. The effects of Aucubin on osteoblast and osteoclast were examined in mouse bone marrow-derived mesenchymal stem cells (BM-MSCs) and RAW 264.7 cells, respectively. Moreover, the lncRNA H19 and Wnt/β-catenin signaling were detected by qPCR examination, western blotting, and luciferase activity assays. Using the femur fracture mice model, the in vivo effect of Aucubin on bone formation was monitored by X-ray, micro-CT, histomorphometry, and immunohistochemistry staining. In the present study, Aucubin was found to significantly promote osteogenic differentiation in vitro and stimulated bone formation in vivo. Regarding to the underlying mechanism, H19 was found to be obviously upregulated by Aucubin in MSCs and thus induced the activation of Wnt/β-catenin signaling. Moreover, H19 knockdown partially reversed the Aucubin-induced osteogenic differentiation and successfully suppressed the activation of Wnt/β-catenin signaling. We therefore suggested that Aucubin induced the activation of Wnt/β-catenin signaling through promoting H19 expression. Our results demonstrated that Aucubin promoted osteogenesis in vitro and facilitated fracture healing in vivo through the H19-Wnt/β-catenin regulatory axis.

Clinical Study on the Treatment of Long Bone Fracture Non-Union with Extracorporeal Shock Wave Therapy Combined with Platelet-Rich Plasma

Objective: The objective of the study was to evaluate of the therapeutic efficacy of extracorporeal shock wave therapy (ESWT) combined with platelet-rich plasma (PRP) injection in patients with long bone fracture non-union. Material and Methods: A total of 36 patients identified with long bone fracture non-union treated from September 2020 to September 2023 were enrolled into this study. Employing a random number table method, they were randomly divided into three groups, with 12 cases in each group. Based on the treatment modality, the groups were categorized as the ESWT group, PRP group, and combination ESWT + PRP group. Routine radiographs and musculoskeletal ultrasound were obtained before treatment and at 3-, 6-, and 9-month post-treatment intervals to observe for bone callus formation and assess fracture line imaging scores with the aim to evaluate the treatment efficacy of each group. Results: With the extension of treatment time, the bone callus and fracture line imaging scores of the three groups gradually increased (P < 0.05). At 3-, 6-, and 9-month post-treatment, the scores of the ESWT combined with the PRP group were significantly better than those of the singular ESWT group and PRP group, and the differences were statistically significant (P < 0.05). Conclusion: Therapy with singular ESWT, singular PRP, and combination ESWT + PRP has demonstrated effective improvement in fracture healing for patients with long bone fracture non-union. The synergistic effects of combination therapy were more significant, surpassing the efficacy of singular ESWT or PRP applications. The combined use of ESWT and PRP represents a safe and promising alternative treatment for long-bone fracture non-union, making it a compelling choice in the context of fracture healing. Keywords: Extracorporeal shock wave therapy, Platelet-rich plasma, Non-union of fracture.

The Role of Recombinant Parathormone derivative in Bone healing. Making the Unfavorable, Favorable - A Systematic Review

Background: Teriparatide is a recombinant parathormone derivative encompassing the first 1-34 amino acids off PTH, which is said to contain potent anabolic capability. It is said to induce osteoblastogenesis thereby placing an essential role in bone healing. The aim of this systematic review is to evaluate the best available evidence from randomized controlled trials analyzing the effectiveness of teriparatide on bone regeneration and healing in osteoporotic patients and patients with fractures. Aim: This systematic review aims to assess whether Teriparatide enhances bone regeneration and healing in terms of improving clinical, radiographic, histologic parameters and Biomarkers of Bone formation and resorption. Materials and Methodology: A comprehensive search was done in databases such as ‘PubMed’, ‘Google Scholar and ‘Cochrane’ databases based on pre-determined eligibility criteria. Randomized control trials assessing the effectiveness of Teriparatide in Bone healing in fractures as well as osteoporosis were selected after thorough screening. Results: The selected 13 studies compared teriparatide to either placebo or another anti-resorptive drug. Out of the 13, 8 studies were done to evaluate the improvement and healing of bone in Osteoporotic patients whereas 5 studies were done on improvement in fracture healing. The studies evaluated outcome parameters such as Clinical and Radiological improvement, Biomarkers of Bone resorption and formation and Safety.6 studies assessed clinical parameters, 12 studies assessed radiological parameters, 7 studies assessed biomarkers, 11 studies assessed safety parameters by means of occurrence of any adverse effects. All the 8 studies done on osteoporotic patients showed a good improvement. Of the 5 studies on fracture healing, only 2 studies showed beneficial effects while the other 3 did not show any benefits. Conclusion: Teriparatide could have beneficial effects in bone healing in osteoporotic patients and is well tolerated. However, the results are inconclusive whether they have beneficial effects in treating fractures. More Homogenous Randomized control trials are required to ascertain whether teriparatide could improve bone healing.

Nickel\u2013titanium arched shape-memory alloy connector combined with bone grafting in the treatment of scaphoid nonunion

PurposeTo summarize the techniques and clinical effectiveness in treating scaphoid nonunion with nickel–titanium (Ni–Ti) arched shape-memory alloy connector in combination with autologous iliac bone grafts.MethodsThis study retrospectively analyzed 18 scaphoid nonunion cases treated with arched connectors with autologous iliac bone grafts. Based on scaphoid nonunion, 2 cases were classified as type II (fibrous union), 4 cases as type III (mild sclerotic union), 6 cases as type IV (moderate resorption and sclerosis), 5 cases as type V (severe bone resorption and sclerosis), and 1 case as type VI (pseudarthrosis formation). At the first 4, 8 and 12 weeks after the surgery, wrist anteroposterior, lateral X-ray were obtained, respectively, to evaluate bone healing. Patients who had not yet reached the standard of healing at 12 weeks after surgery would continue to receive additional appointments for follow-up visits, such as 14 weeks, 16 weeks, 18 weeks after surgery, until their imaging studies had achieved satisfactory bone healing. Clinical effectiveness was evaluated comprehensively, based on bone union time, Mayo wrist score, and visual analog pain score.ResultsAll 18 patients achieved satisfactory reduction and fixation with a mean union time of 4.2 months. Preoperative Mayo wrist score averaged 57.4 and average final postoperative follow-up was 91.4. On the other hand, mean preoperative VAS score was 6.8, and final postoperative follow-up average was 1.6. Mayo wrist score of the overall treatment effectiveness was excellent (90–100) in 12 cases, good (80–90) in 5 cases, and acceptable (60–80) in 1 case with zero poor (below 60) cases observed. Statistical analysis suggested that a statistically significant improvement in fracture healing, wrist function recovery and visual analog pain after surgery when compared to the scores of the patients before surgery.ConclusionUsing Ni–Ti arched shape-memory alloy connector in combination with autologous bone grafting provided a new modality to treat scaphoid nonunions in a less traumatic, convenient to operate and satisfactory manner in treatment outcomes, and thus is worthy of further application.

Hypoxia and mesenchymal stromal cells as key drivers of initial fracture healing in an equine in vitro fracture hematoma model.

Fractures in horses–whether simple fractures with just one clean break, or incomplete greenstick with stress fractures, or complications such as shattered bones can all be either minimal or even catastrophic. Thus, improvement in fracture healing is a hallmark in equine orthopedics. The fracture healing process implements a complex sequence of events including the initial inflammatory phase removing damaged tissue, re-establishment of vessels and mesenchymal stromal cells, a soft and hard callus phase closing the fracture gap as well as the remodeling phase shaping the bone to a scar-free tissue. Detailed knowledge on processes in equine fracture healing in general and on the initial phase in particular is apparently very limited. Therefore, we generated equine in vitro fracture hematoma models (FH models) to study time-dependent changes in cell composition and RNA-expression for the most prominent cells in the FH model (immune cells, mesenchymal stromal cells) under conditions most closely adapted to the in vivo situation (hypoxia) by using flow cytometry and qPCR. In order to analyze the impact of mesenchymal stromal cells in greater detail, we also incubated blood clots without the addition of mesenchymal stromal cells under the same conditions as a control. We observed a superior survival capacity of mesenchymal stromal cells over immune cells within our FH model maintained under hypoxia. Furthermore, we demonstrate an upregulation of relevant angiogenic, osteogenic and hypoxia-induced markers within 48 h, a time well-known to be crucial for proper fracture healing.

Effects of continuous or intermittent low-magnitude high-frequency vibration on fracture healing in sheep.

Vibration therapy has been shown to improve fracture healing. In this study, we investigated the effects of continuous or different intermittent vibration regimens on fracture healing in sheep models on the basis of radiographs, mechanical, and biochemical testing. The 63 right-hind metatarsals from 63 sheep (12-month-old) were osteotomized; followed by surgical fixation with a steel plate. Two weeks after the surgery, the sheep with right-hind metatarsal fractures were randomly divided into seven groups (n=9/group): control (no vibration treated), continuous vibration (CV), one, three, five, seven and 14-day intermittent vibration (named IV-1, -3, -5, -7, and -14, respectively) groups, which represented a cycle of the successive n-day vibration and successive n-day break. Vibration stimulation (F=35 Hz, a=0.25 g) lasted 15 minutes each treatment. After eight weeks with/without vibration treatment, the sheep were euthanized with intravenous anesthetic. The callus formation, mechanical properties, and biochemical compositions of fracture metatarsals were analyzed. In CV and IV-7 groups, X-ray images showed an increased callus volume around the fracture area. The bone elastic modulus and the concentrations of Ca, P, and Ca/P ratio of the area at 15 and 25 mm away from the fracture centerline were higher in CV and IV-7 groups compared with the other groups. Our results demonstrate that both CV and IV-7 vibration patterns showed better improvement of fracture healing.

Does a single high dose of vitamin D3 have an effect on fracture healing? Animal study

<p class="abstract"><strong>Background:</strong> Vitamin D has an important role in the regulation of calcium by stimulating intestinal absorption of calcium and phosphorous and osteoclastic resorption of bone thus being critical building bone. Given the high prevalence, severity, and cost of osteoporotic fractures, prevention strategies that are effective, low in cost and well tolerated are needed. One promising prevention strategy may be vitamin D supplementation. This animal study was done in order to establish the role of Vitamin D in fracture healing among rabbits.</p><p class="abstract"><strong>Methods:</strong> 8 rabbits were involved in the study with 4 in the control group & 4 in the test group. A fracture was surgically induced on both the groups following which a single high dose of vitamin D was administered intra muscular injection to the test group and normal saline for the control group. Biomechanical properties of the fractured bones such as energy absorbed until fracture (EAUF), maximum load (N) and diameter at the fracture site (D) were assessed 12 weeks later.<strong></strong></p><p class="abstract"><strong>Results:</strong> Mean value of EAUF for test group was 401.8 N-mm and control group was 404 N-mm. Mean value of maximum load in control group is 228.8 N and for test group is 186.9 N.</p><strong>Conclusions:</strong>From the above results, the authors did not find any significant improvement in fracture healing in test group. Hence, further investigations are to be needed to prove the role of vitamin D3 in fracture healing.

Therapeutic Effects of Sildenafil on Experimental Mandibular Fractures.

No previous studies have examined the effect of sildenafil on fracture healing. This study was designed to investigate the effect of sildenafil on the fracture healing process. Thirty-six female Sprague-Dawley rats (3-month-old) were used in this study. Animals were randomly divided into 2 groups based on treatment duration (1 week versus 4 weeks) and each group was then divided further into 2 subgroups, control (C) and study (S) groups. Group C (C1, C2) was treated daily with saline solution and group S (S1, S2) was treated daily with 10 mg/kg of sildenafil. Histologic, histomorphometric, radiological, and immunohistochemical analyses were performed at 1 week and 4 weeks after a fracture. The sildenafil group showed a significant increase in fracture healing scores (P = 0.00). The authors observed a transition from fibrous callus to cartilage tissue and immature bone tissue in group S1; and an increased transition of cartilage tissue to completely immature bone tissue in group S2, both of which were administered sildenafil. The strong expression of bone morphogenetic protein 2 and col-1 was observed in the fibrous matrix and osteoblasts within areas of new bone formation, especially in group S1. This group also showed an increase in bone density measurements at 1 week that was statistically significant (P = 0.03). Sildenafil accelerates fracture healing and can be used as a supporting factor in the improvement of fracture healing under various conditions.

Histological and biomechanical effects of zoledronate on fracture healing in an osteoporotic rat tibia model.

This study aims to investigate the effects of zoledronate therapy on histological and biomechanical properties of bone healing via a fracture model generated on osteoporotic rat tibiae. Ovariectomized 40 Wistar-Dawley female rats weighing 300 g to 350 g were used in the study. After one week, 2 IU/g heparin injection was started subcutaneously. After four weeks of daily injections, osteoporosis was ensued proven with bone mineral density measurements. Osteoporotic rats were separated into four equal groups randomly as group A (control), group B (calcium and vitamin D), group C (0.1 mg/kg subcutaneous zoledronic acid), and group D (calcium and vitamin D / 0.1 mg/kg subcutaneous zoledronic acid). Six weeks later, all rats were sacrificed, their tibiae were resected, and histopathologic and biomechanical studies were performed. Group C (30.2±1 Nm) and group D (33.3±3 Nm) had significantly higher peak torque values than group A (21.6±6 Nm) and group B (23.6±4 Nm) (p=0.007 and p=0.005, respectively). Group C (1.8) and group D (2.0) had higher stiffness values than group A (1.4) and group B (1.7); however, the difference was not statistically significant (p>0.05 for all). According to histopathological and biomechanical test results, single dose zoledronic acid treatment improves fracture healing in an osteoporotic rat fracture model. Orally administered daily calcium and vitamin D treatment had no effect on fracture healing. There was no additional improvement in fracture healing when calcium and vitamin D treatment was added to zoledronic acid treatment. Positive effects of zoledronic acid treatment on osteoporotic fracture healing and callus quality should be shown by future clinical studies.

Cannabidiol, a Major Non-Psychotropic Cannabis Constituent Enhances Fracture Healing and Stimulates Lysyl Hydroxylase Activity in Osteoblasts.

Cannabinoid ligands regulate bone mass, but skeletal effects of cannabis (marijuana and hashish) have not been reported. Bone fractures are highly prevalent, involving prolonged immobilization and discomfort. Here we report that the major non-psychoactive cannabis constituent, cannabidiol (CBD), enhances the biomechanical properties of healing rat mid-femoral fractures. The maximal load and work-to-failure, but not the stiffness, of femurs from rats given a mixture of CBD and Δ(9) -tetrahydrocannabinol (THC) for 8 weeks were markedly increased by CBD. This effect is not shared by THC (the psychoactive component of cannabis), but THC potentiates the CBD stimulated work-to-failure at 6 weeks postfracture followed by attenuation of the CBD effect at 8 weeks. Using micro-computed tomography (μCT), the fracture callus size was transiently reduced by either CBD or THC 4 weeks after fracture but reached control level after 6 and 8 weeks. The callus material density was unaffected by CBD and/or THC. By contrast, CBD stimulated mRNA expression of Plod1 in primary osteoblast cultures, encoding an enzyme that catalyzes lysine hydroxylation, which is in turn involved in collagen crosslinking and stabilization. Using Fourier transform infrared (FTIR) spectroscopy we confirmed the increase in collagen crosslink ratio by CBD, which is likely to contribute to the improved biomechanical properties of the fracture callus. Taken together, these data show that CBD leads to improvement in fracture healing and demonstrate the critical mechanical role of collagen crosslinking enzymes.

Effects of α‐tocopherol on the early phase of osteoporotic fracture healing

Fracture healing is a complex process, which is more complicated if the bone is osteoporotic. One of the vitamin E isomers, α-tocopherol, has been found to prevent osteoporosis and improve bone fracture healing but its role in the healing of osteoporotic fractures is still unclear. We carried out a study on the effects of α-tocopherol supplementation on osteoporotic fracture healing using an ovariectomized rat model, whereby we focused on the early phase of fracture healing, that is, the phase with excessive production of free radicals. Twenty-four female Sprague-Dawley rats were divided into three groups: sham-operated (SO), ovariectomized-control (OVC), and ovariectomized + α-tocopherol supplementation (ATF) groups. The right femora of all the rats were fractured at mid-diaphysis and K-wires were inserted for internal fixation. After 2 weeks of treatment, the rats were euthanized and the femora were dissected out for measurement of callous volume by CT-scan and radiological staging of callous formation and fracture healing. The oxidative parameters of the fractured femora were also measured. The results showed that the callous volume and callous staging were not different between the groups. However, the fracture healing stage of the OVC group was lower than the SO group, while α-tocopherol supplementation in the ATF group had improved the healing until it was comparable to the SO group. The activities of the anti-oxidatant enzymes, superoxide dismutase, and glutathione peroxidase in the ATF group were found to be significantly higher than in the OVC group. In conclusion, α-tocopherol improved fracture healing but had no effect on the callous volume and staging. The improvement in fracture healing may be due to the increased activities of the anti-oxidatant enzymes in the bone during the early phase of fracture healing of osteoporotic bone.

Improvement of fracture healing by systemic administration of growth hormone and local application of insulin-like growth factor-1 and transforming growth factor-β1

Fracture healing is influenced by numerous hormones, growth factors, and cytokines. The systemic administration of growth hormone (GH) has shown to accelerate bone regeneration. Local application of growth factors, such as insulin-like growth factor-1 (IGF-1) and transforming growth factor-β-1 (TGF-β1), are known to stimulate bone metabolism. Until now, the exact local and systemic mechanisms that lead to improved bone regeneration remain unclear. In addition, the effect of systemic administration of GH as compared with locally delivered growth factors on fracture healing in rats is not known. A midshaft fracture of the right tibia of 5-month-old female Sprague-Dawley rats (n = 80) was intramedullary stabilized with IGF-1 and TGF-β1 coated vs. uncoated titanium K-wires. The growth factors were incorporated in a poly(D,L-lactide) (PDLLA) coating and released continuously throughout the experiment. Recombinant species-specific (rat) GH was applied systemically (2 mg/kg body weight) by daily subcutaneous injection and compared with a placebo group. The healing process was radiologically monitored. Twenty-eight days after fracture biomechanical torsional testing was performed. The consolidation and callus composition, including quantification of cartilage and mineralized tissue, was traced in histomorphometrical investigations using an image analysis system. Both methods, the systemic administration of GH and the local application of growth factors, showed significant biomechanical and histological effects on fracture healing. The local growth factor application showed a stronger effect on fracture healing than the systemic GH injection. The combined application of both methods did not accelerate the effect on bone healing compared with the single application. It is therefore concluded that combining local and systemic stimulating methods does not provide further additive effects with regard to fracture healing.

The effect of protein malnutrition and nutritional support on the mechanical properties of fracture healing in the injured rat.

We investigated the effect of different nutritional regimens on fracture healing in the injured rat model. Four groups, each consisting of 12 male rats (307 +/- 16 g), were subjected to anesthesia, laparotomy (injury), and tibial osteotomy with internal fixation. Group I received 23% protein, group II received 23% protein and high caloric feed, group III received 5% protein, and group IV received 38% protein. After 8 weeks, calluses were x-rayed and the tibia was removed, fixed in a special block of methyl-metacrylate, and tested at tension up to failure in a mechanical testing apparatus. The distraction force at failure was measured, and callus stiffness and energy absorbed to failure were calculated. The low protein diet resulted in significantly lower tensile strength and stiffness of calluses compared to the other three dietary regimens, this despite adequate caloric intake. In addition, the low protein diet resulted in a callus with "rubbery" mechanical properties compared to the "rigid" calluses of the other three groups. The high protein diet did not result in any significant improvement in fracture healing. These results gain clinical significance in the face of a high incidence of protein calorie malnutrition in injured orthopedic surgery patients.